With age-appropriate tests and tools, primary care providers can identify vision concerns in very young patients before there are lasting effects. In this video, UCSF specialists discuss screening methods and offer a case-based look at the diagnostic process for issues ranging from amblyopia to ocular tumors. Also included: criteria for urgent referrals.
uh, I'm Talita Queen Angle is the new pediatric ophthalmologist that China's Hospital and I'm looking forward toa working with out of you So today we'd like to talk about when to call your neighborhood Pediatric ophthalmologist Eso Pediatricians should always include pediatric vision screening in their routine care off Children. Thea American Association for Pediatric Ophthalmology Industry Business has published the guidelines to promote early um, detection and treatment off vision treating conditions. Eso I will be talking more about vision screening and as you'll be showing interesting cases later. So our learning object today is to appreciate the importance off vision screening during childhood. Also understand methods off visual acuity, screening and appreciate new technologies that can identifying signs off potential vision, loss of problems. So why to perform vision screening. So primary care providers are the first line off the fans to avoid vision laws in Children. And why do Children lose vision in Ethiopia is the most common cause of vision loss and Children in Ethiopia is a decrease in vision development that happens when the brain doesn't not get normal stimulation from the eyes and this'll abnormal development off vision results, uh, when one or both eyes send unclear image to the brain, and the brain is unable to learn to see clearly with that, I even when glasses I used so only Children can get on video Pia and it's not treated in childhood. It results in permanent loss of vision in blue Opa. It's most commonly caused by untreated reflective Eros, extra business and other visionaries orders such cataract glaucoma. Fortunately, pediatric vision screening can reduce the incidence off vision loss related to embryo PIA and the earlier that amblyopia is the fact the better the visual recovery and the long term prognosis. Permanent vision loss occurs by seven years Off age amblyopia effects 2 to 3% off Children in the United States. In Children who can collaborate, direct measurements off visual acuity using charts remains the gold standard for vision screening. So for newborn and kids below three years old, it's important to take a half history, including eye problems in close relatives. We have to check if the kid has the ability to look and follow a moving object from side to side. Up and down corner light reflects our over casting, are really important to the texture, business and We also have to check the eyelids and pupils, and red reflects is so. The Red Reflects test is a no evasive task that can show early warning signs off serious eye conditions. In Children, we usually perform a red reflects task musing on off Thomas Cope. Absent bread reflects or a white I grow maybe signs off serious eye disease in Children, including rich novel Storm in a corner light reflects staffs. The child's intention is attract toe a target. While delight, it's pointing at the child's eyes. In kids with distributes most, the light reflects will not be in the center off each purple. So here is a video to demonstrate the alternate cover test and how to detect this your business In Ortho Fauria, there is no movement of either I when the cover is moved back and forth from one eye to the other. If re fixation is seen each time the cover is moved, this may indicate a hetero TRO. Pia re fixation movements each time the cover is moved are also seen in hetero Fauria in hetero Fauria Fusion a lover Jin's restores normal ocular alignment as soon as binocular viewing is allowed right eso soon. Mr Business is a condition that you see very often in our clinic, and it's when the child appears to have a really strabismus because off the enlarged AP Cantel folds. But look at this picture in the bottle and the note that the light reflects this symmetric in each eye and still distribute business. Go away as the baby's face begins to grow so Children aged 3 to 4 years old must be able to see 2050 with each eye and the test and should be done at 10 ft. So we recommend a layer symbols H O T v letters for visual acuity measurement uh, dumbly in charge. It's not recommended for Children aged 3 to 4 years old, as it requires a spatial orientation excuse and young Children may not yet have the ability to express the orientation off those opta types. Children aged between four and five years old must be able to see 2040 with each eye and above five years old. They must be able to see 2032 or 2030 with each eye depending on the charge used, and it's important to repeat the task everyone to two years. So let's talk about the 40 screening. So those devices are often very useful in Children between one and five years old. But they do not replace visual cutie screening with eye charts in older Children. So what is the difference between the vision screening with my charts and instrument based in screening device? So visual screening with eye charts test the actual visual could be like 2030 2020 2040. And the visually screening device typically do not test visual acuity directly. Uh, screening device. That's for one point I conditions or risk factors that can cause decreased vision or in the utopia. So those devices take a photographic image off the eyes, Red reflects or some other measurements to estimate the prescription off the ice. They also made attacked ocular alignment and other conditions such as cataracts. So here we have some common instrument based device. My favorite. It's the plus opticals from Germany. Eso I just wanted to emphasize that direct measurement off visual acuity using vision charts is the current gold standard for vision screening. Unless the child it's not able to perform such a test. So what is? Screeners are more generous for young Children. There is a higher detection and referral rates and fear of false positive but higher chance off missing at risk Children. And it's not recommended for Children older than six years off age. Uh huh. Eso When the child fails vision screening, it's important to check if the kid was having a bad day. Waas distract and also check the numbers on the device. We're not going to prescribe glasses for kids with astigmatism less than 1.5 to die otters or myopia less than three for kids below one year old. So those kids are not going to wear those glasses. And, uh, these astigmatism around one point 1.5 or two will not cause on Theo Pia unless the kid has this difference. Refractive power between the two eyes above two Diop tres or more so checking the numbers on the device are really important before making and refer to us. So when you needed to refer a patient to us so below one year old refer Children who do not track well after three months off age and Children with an abnormal red reflects or history off retinoblastoma in a parent or sibling between one year and three years old. Refer Children with extra business, Cornick triggering and discharged Children who fail for the screening between three and four years old. Refer Children with vision less than 2050 and between 54 and five years old. Refer Children with vision less than 2040 and off course of Children who fail for the screening and with sister business. So five years old or older refer Children who cannot read at least 2032 with either I or Children who are not reading at great level. And And, of course, it's the business cases. And we have to repeat the division screening every 12 years after age of five. So so we can find that those vision screening kit on April's website. That's easy and thank you. So now as um is gonna show us some interesting cases, So thank U S. So we'll get started. Okay, So what we're gonna do in my president, my portion is we're going to kind of go over some chief complaints that my presented your clinic and I want to walk you through what? You know, we hope you guys can do and then what you guys definitely need to send to us for I tried to choose five of the most common, um, presentations, so that would that would kind of apply to what you've seen your clinic that you would need to send us eso. I think it will be very useful to take a look at these and we can talk about how to manage them. And I'm looking forward to the questions of the end. Um and yeah. Then we are definitely gonna mention where we intervene and how we intervene in those specific cases. And I'm also gonna gonna take a second to go through the differential diagnoses of each of these and kind of talk a little bit about each of them And like, what? What this case is and what it could potentially be and why we need to see it or why we don't need to see it in in those circumstances. All right, so case one mother has noticed that are otherwise healthy. Six month old baby uh, baby's eyes have been crossing significantly since birth. The ice, it seems to alternate, which I was crossing. Okay, so it's a very common presentation in our clinic, Not probably not super common in yours, but does come up eso The differential diagnosis for this patient is pseudo east a tro pia Congenitally Sutro, Pia accommodated visa trope via non accommodative a quality strop A in the six term falls. So we're gonna go through the first one differential. So the first differential pseudo he's a trophy A And so, in some ways, a trophy A You know, there's a prominent epic Cantel folds and the flat nasal originally Look over here. You see how this is kind of moving in the eyes, Actually, pseudo means the eyes were not actually crossing it. Just a piers at the crossing it when the kid looks, the mom and dad was gone. When the kid looks like it looks like they're crossing when the kid looks right looks like when they look straight, it looks straight in the eyes. Look straight but for some reason it looks like this. And so you know what I do in my clinic is often times I'll pinch the skin right here and also like this. What will look like when they're when they're knows develops fully and you'll see that the eyes looked very straight. Um, and the way we kind of know that these kids don't actually a visa trophy is you can look at these corneal reflexes, this little this little white little dots you're seeing here when you shine a penlight on these kids and you can see that they center right in the center of the pupil, even though the appearance looks like the eyes might be crossing eso If they're actually crossing with these, these little lights will be on the on the color part of the iris, not in the center. Um, also, there is no there is like Typically, these kids will dilate them when they come in our clinic, and they don't have a refractive error. And so, typically, these were just no intervention. But these kids are always welcome on a clinic. If you're unsure, you feel free to send it to us because this is something that you know shouldn't be missed. If it is another diagnosis, so that moves into can generally see trophy a. So this typically presents by six months of age on bond. You know, these kids sometimes have ah refractive error. But as Toledo mentioned It's normal for kids to have a small amount of high propia when they're young, where that's not concerning. And actually, the glasses typically won't help these kids for the amount of crossing they have. Um, what you'll notice is they do something called cross fixating. And so when they're looking to the left there using the right eye and when they're looking to the right there using their left eye. And that way they don't have to ever move the either. And what you'll notice is if you patch one of the two eyes, you'll see that, oh, all of a sudden that the other eyes moving around all over the place and and typically like if a If a kid has a specific type, I'll actually do prescribe alternate patching until I do surgery. Just to make sure that I've treated all the amblyopia before I do my surgery and sometimes, like in in in rare occasions, you'll see that just doing the patching. Actually, sometimes the kids don't even need the surgery, so you know, if you see a kid and you're 100% sure that their eyes cross, then feel free to start doing alternate patching before they see us. But this is something that you know. If you're sure they're crossing, they have s a trophy. There's six months of age. We like to get them into our clinic relatively fast because these kids need surgery and the reason they need surgery fastest. It will preserve their ability. If we do surgery soon, it has a higher likelihood of preserving their ability to use both of their eyes together and to have good three D vision. And so here's kind of a little slide, and it shows that if you do the surgery, um, in the 7 to 12 month phase after they've seen the crossing, your likelihood of getting good three d vision after surgery is significantly higher than if you wait thio like, you know, two years of age or even a year in a month. So while Toledo mentioned it is important, the kid has embryo. If a kid has like a refractive error, plus 1.5 on and they failed a vision screen because of one doctor of astigmatism, and maybe that's something you know we don't need to see right away because we're probably going to have the glasses. But this is something that if you see and I crossing and your concern this something where we do tend to intervene pretty fast and you got you guys can definitely call our clinic, and we try to get them in, streamline their visit appointment. And so you know, the question comes up. Is that a lot of this because why their eyes crossing? Why don't they see double? So kids brains are actually very flexible. As I'm sure you guys are aware is pediatrician's um so what they tend to do is kids actually can can block one of the eyes. And so what they're doing is the eye that's cross. They basically turning the eye that's crossed off, and then they're only using the other eye. And then right when they closed that other I the the I that they turned off turns on. So they Onley turned the eye off when they only turn the eye off when both eyes air open. And so this is called the Scott Oma and the suppressions Katona, and it's the way kids still see single despite the eyes being crossed. And if an adult has, you know, and I cross them like that. They tend to see double if they haven't had it their whole life. And this Katima can stay. And that's why I like a lot of these kids here and they end up not like the kids that don't get a perfect stereo vision. They still don't see double upwards because their brain kept the Scott Oma. And so our mission is trying to decrease this Cantona's presence, uh, Tua's Lola's possible to small oven areas possible so the kids sees single and three d ast much as possible. Eso Now we're gonna move in to accommodate a visa trophy A. So this is different. So this is gonna present after the age of one and the eyes aren't gonna be dramatically crossed. And what? The main thing is that you're going to see on exam. When we examine them, we see that they have a large refractive error there typically hyper opic toe the ranges of plus three, two plus seven. Um, and sometimes you know, you give them most of times you give these kids the glasses and the result of dramatic. So this size cross, you can see it here. It's crossed. You put the glasses on them, and then all of a sudden, that's fixed. But sometimes it's it's accommodated and has a non accommodative components. So sometimes you put the glasses. It fixes a little bit, but it doesn't fix all the way. And so those kids typically fire on a dish a surgery on top of one of the glasses. But when we do the surgery, we typically do it so that they'll still wear the glasses afterwards on. The extra amount is just for the same thing. To kind of get rid of this suppressions Katima. It's the same thing in that happens in general is the trouble. We're trying to get that down to nothing and and like, they need the glasses because they're actually typical really hyper OPIC or that's farsighted. So these are a little bit more uncommon in pediatric populations, and we kind of look out for these cranial nerve six policy and you know, you can kind of see that in your in your clinic. Uh, it's very dramatic if they have a cranial nerve six party, because what you'll notice is, uh, for some reason, one I can't go out on the other I goes in dramatically, and even then, it might not be a creative six. Policy can also be a something called Duane Syndrome. Um, but, you know, if you have any concern about that using that dark clinic and and we'll we'll we'll work on figuring out another thing is sensory used utopia and, you know, typically kids under one if one of their eyes doesn't work like like a very common diagnosis I've seen that's been sent to my clinic is optic nerve hyperplasia and thes kids come to my clinic and, um, they ever trying to rule out the Morsi syndrome and and they have a mildness stagnant. And but for some reason, one of the eyes isn't working super well. And so if you're under the age of one, what happens at that eyes not working well, it goes in the brain, turns it off, and it tends to go in. And if after the age of 1 to 2, if you know you get an injury to a night or something, and if you weren't born with that, typically that I will go out So centuries. A trophy is typically something occurs in younger population and Finally, there's another thing and I have had two or three. These based on my clinic, is called Nystagmus Blockage Syndrome. On this is basically kids, you know, nystagmus is when the eyes air wiggling right and so away that away that a patient can stop My stagnant is by convergence. So convergence is bringing the two eyes together so you'll see a lot of patients they actually don't. They're not crossing. What they're doing is they're dampening their next Agnes on. That's by doing this thing. And so typically, if it's really dramatic, you can. You can do surgery for them and help them fix it. So that kind of goes through crossing and and the main, the main, the main ones. I didn't cover Dwayne syndrome, which is a little, you know, a little bit more advanced, but I'm sure we would see those places. We saw them in your clinic anyways, Um so so for this patient mother's nose on otherwise healthy six month old babies, I, who's been crossing significantly since birth, seems to alternate, so this one was generally the trophy. Because of the age, the age is very important for the presenting less than six months, less than a year of age. It's usually gonna be in general is a trophy, and it's usually pretty dramatic presentation. Thes will require surgery. And as I mentioned, if we do the surgery promptly, oftentimes the results are better than if you wait. All right, Now we're gonna look a case to constant tearing out of left. I'm others noticed that are otherwise healthy. Three year old son has been tearing since birth, and it's sometimes appeared to have Purell and discharge. Mother noticed that the eye has never been read. So this is a picture of this presentation. Okay, So s so this is you know, there's not much tricks to this. What this is this is a congenital nasal, lockable duct duct obstruction. Um, there is an typically, you know, a lot of kids have this, but it resolves on their own by the age of one. And what you'll see is the reason they have it is there's a imperfect valve that the valve has, and I'll show you the anatomy of got in a in a second slide. And, um, most of times, these results on their own by the age of one 90% of cases resolved. I've actually had one resolved in the middle of my clinic. I'm just pressing on it and just resolved. And so it's great if that happens. But if it doesn't happen after the age of one, that's kind of when we tend to do an intervention. Here is kind of a little bit of anatomy. Your here's your punk them and you can see it. If you flip your eyelids open, you could see a little hole. That's where the tears strain. This is your candle Oculus right here, Upper and lower Canada Oculus. And then when you close your eyes, it squeezes these and it pushes things into your lack criminal sack. This is called your Lakmal sack, and then from your lack of Mossack things going to your lack of duct and that this empties out below the inferior V a tous and into your like nose. And so you know, your nose runs up, you cry basically right, and so that's kind of the same. This is kind of, um, example of this anatomy on configuration. Typically, what happens in these kids is they haven't imperfect developed Hasner, which is over here And so they're unable to get the tears. The tears get blocked up and eso you know, the treatment for these kids is eyes, you know, way if it's not resolved after the age of one, will recommend the Crigler massage, and then after the Kremlin massage weaken, do a probing of this system. And we do the probing under general anesthesia, Typically some pediatric pediatric, but most will do it in the clinic, but way don't do that here. Um, it's kind of controversial to do that. Um, this is, um, or severe version of the same thing. So this is called a Dockery assistance. I want to share this with you guys. So if this presents you know this if you're seeing a babies in the hospital and you see, this is kind of something a little bit more urgent, slash emergent. And so this has an island island bump on the third day of life and the same thing. Um, the sack is distended. The lack of ball sack is distended. And there what can happen here is because it's distended and stuff staying inside of there. It could become infected and even cause something called a decree of cystitis and then the overlying skin king of pre septal cellulitis. So typically, if you see these, we I've had two of these over the course of the year here, and we like to give antibiotics. Calm down the skin infection on, calm down. The doctors and scientists watch, even get some labs, they admit Get amid for observation. Then within a day or two, I'll do the program and irrigation. Um, yeah. So this is typically, you know, below the nasal immediately below a nasal to the medial Kansas. You could see in that photo a turmoil cyst will typically be a lateral canvas and above, and it won't be read. And then encephalitis. It will be above the medial campus. Okay. Hm. Ngoma, They're just gonna be bright red. They're gonna be wherever they're not gonna look Infections. There's gonna be no discharge. And so, like I said, we wanna do digital massage and probing in clinic will probe the doctor Sister seals and try Thio. Take out as much pure Eliza's possible, because it helps them kind of relax a little bit before we we do the program irrigation. Okay, So our patient was mother's noticed her otherwise helping three year old son. So this is three and, as I said, 90% resolved by the age one. And so for this case is like Well, you have generally Oh, that didn't resolve. Probably enough to do you under anesthesia and you can attempt to critical massage in the meantime. And so if you see a kid like this in your clinic and there's a great recommendation for you guys is seldom do the cradle massage and then get them referral to us. Um, after the age of Wanda, unless it's obviously a diagnosis to see which we need to see the emergence. Alright, eso white in the center of I. So this mother has noticed that otherwise healthy four week old baby born full term has a white cloud in her left eye. So this is called Luca Korea. Differential Diagnosis Luke Korea's congenital cataracts retinoblastoma, which is kind of like the first thing you see right now. So if you see this, you have to rule this out immediately. That's like your first thing. I got to roll this out fright. Worry about anything else because, as we know the, it's a tumor suppressor gene, and there could be other tumors. And it could be other things going on. And you have to really kind of take care of that aggressively. Um, and obviously, we don't do that here. We would get ocular oncologists involved in the management of that, um, and then talk. So CMB, retinitis rop, these other causes and p HPV primary hyper plastic primer, vitreous persists, high plastic primary vitreous. And that's gonna be another cause of this. So as I mentioned, I always So I had one of these this morning, and I'm going to show you the video from this morning. I did a congenital cataract this morning on a three month old, and I always do an exam under anesthesia before I removed the cataract to make sure that the base doesn't read in Boston. And so I'll do a B scan and And when I do the b skin, I'm looking to make sure there's no hyper calcification along the posterior pole and make sure it's nothing different in my patient today. There was none of that eso It was the instance of these cataracts and kids, so this is probably gonna be a cataract right about 150. But, like, man, that's that sounds like a lot, right? But the reality is, there's a lot of cataracts, but they're usually typically really small, and most of them are not getting surgery. Sutra lung capacities, air really small. Don't. They're not very significant. These kids are gonna develop normal vision if I don't do surgery. So I'm just watching their interior cataracts and and, um, the nuclear cataracts. I'm just watching most of them. Unless division drops around 2080 then I start to consider to do something, But most the time It doesn't. Um Now, when do I do surgery? When I do surgery is if I see dense bilateral cataracts and and, you know, if I can't see pass it into the sea, the retina, then I know they're not seeing out to see into the world. So then I'm I'm thinking in my mind like, Okay, this is time to do surgery, Onda. Typically, if it's bilateral, I do surgeries a few days apart. We recently just got a war time allocated to us. Kind of like I have now a day every like, one week and a half, and I keep some time open in case one of these come in like this one that I did today was given to us what we saw in clinic last week so we could get them in this week. And we could keep it within the recommended period of 61st of 6 to 8 weeks of life. And so, um uh huh. And then finally, density lateral cataract. You would think a dense bilateral cataracts worse than a dentist in a lot of cataract. But the reality is a density lateral cataracts actually mawr concerning, um in a sense, because what's happening is the brain, as until he was mentioning, you know, one eye is basically being favored over the other I because of the cataract. And so what's happening is once if you have to remove that cataract very fast because if not, the brain will block out that I completely and it will only use the other eye. And so surgery as soon as possible. And you know, because we don't want that other I favorite. And right after surgery you will be patching the good I toe you start using the cataract. I s O that it can catch up, basically, and even if it catches up, that those first six weeks of life or some point that it might not even be enough. So after we do them, I typically leave them a fake IQ if if their infantile, if they're above the age of one or two, I will start putting lenses in. But today, for instance, I didn't put a lens in, Um, because there's like a study that's been done by a non optimal. So Stanford, the Infanta figure treatment, studies a nationwide study, and it showed putting in secondary putting it. I was too early, had a little bit higher negative outcomes, and so I kind of pulled off. Unless there's a reason for me to put it in, like the families unreliable, and I don't know if they're gonna be doing the patching and stuff, I don't know they're gonna cooperate. Then I'll put the lens in just cause I don't want to take any chances, and that is probably better outcome. So there is a clinical indication to put the lenses in under 12 months of age. After 12 months of age, almost uniformly put the lenses in eso. What was this baby. So this baby, you know, infantile cataract possibly left persistent hyper classic primary vitreous. But that would not change the management, Andi. Then urgent surgery, followed by a contact lens from prevent Indio. Pia, I could just walk you through this brief, but this is from this morning. Actually, I did this surgery two hours ago, and you can just see Here's a dense cataract right there and then here. You know, I'm going in. I'm making two incisions on the outside, getting in there, getting the cataract on. You stay in the outer shell of the cataract. Yeah, go and then you start to remove it. And so we use this thing called a detractor, and we will for congenital cataracts, at least. And you typically go on. You just kind of remove out the substance. The material. This patient had a cataract. It was on the back portion of the lens. So what I do now is it's just me were moving in, and then I make a little seen that this little just little hole right here is the opening. I make so that later when the kids older after they've done their lens, they've done the contact lens for several years. I can put a new implantable lenses in older age and predicted in such a way that they don't need glasses. And so I try to do it and be really exact on it. Onda. Typically, if you wait till the age of seven and they do contact lenses you could get exactly. That's why I don't do it before the age of two, because it's unpredictable your outcome. What is going to be even if you follow the best tables? And so there's still that posterior cataract and right there, that still there on moving I around a lot. Sorry as I did this this morning, I It's the video editing wasn't great. Um, but you can see right here. Now I start to go for the posterior portion, and this is the most mostly a posterior contact. So these cataracts could be anywhere. They could be anterior posterior and said this was a posterior one, and you can see here. Now I'm starting to pull this guy out, and so I had to increase the strength of the pull on it to get this guy out. Thank you. Fast forward a little bit more. And so there's a so every one of these kids, if you don't remove the back layer of the cataract, they will come back and they'll have something called the secondary cataracts. So on on infants, I always remove the secondary cataracts. So this is the secondary cataracts already kind of there. And so there's no question on this when you remove it in in the survey as opposed to leaving both actually intact. So right now, that's what I'm doing. I'm removed. First, I'm removing that air bubble, and then I'm removing this posterior, this posterior a passage e and you'll see I'm just cutting around it slowly, and it's gonna slowly start to disappear. Sure, that's my hand, because you don't wanna, like exposed too much white to the kid while you're not doing anything. And then here I go See, now I removed that post your pole, and now the central portions open, and this is considered a surgical success on DSO now. But the surgical success is not really surgery. It's now how you manage the kid after surgery, and how much patch do you do because this kid on Lee had a unilateral cataract and um, S Oh, that's kind of how we judge how how good you did. Alright, So case four. I wondering. Mothers noticed that her otherwise healthy six year olds I wandered outward throughout the day. She reports That mostly happens while the patient is tired or has just awoken. Sometimes while daydreaming. Even it could be either, I mom reports. So this is this is different than the eye going in. That's Easter trophy. This is extra topia, and in some cases it's the same thing. There's an extra. There's a pseudo extra trophies, something it looks like the eyes were wandering, but they're actually not. There's also congenital except opiates, when the eyes have been wandering since birth and it's always present. And in this ex parentheses, T is intermittent. Next utopia. And that is for when the extra topia is sometimes there and but most of time it's not. Finally, the century it's a trophy, As I mentioned earlier in the presentation, it's when, as opposed to the kids I going in when they hadn't been using it early in life. If something happens to kids, I later in life, uh, they have a trauma or something that I will tend to go out if they're not using it. So this is pseudo X T thistles, the one where it looks like the eyes going out. But I was actually not going out because you could see the lights are pretty well lined up. It just looks like the eyes going out. But they typically these were actually, it's weird. The history actually tells you most of these patients. You ask them like I always ask anyone like strop like Were you born full term or where you born Preterm. And if you were born, uh, preterm, you could have had Rop and that can drag your macula outward if you drag your macula outward. What that happens is is to fixate the i u turn your outward so that the images or fixating on your retina. But you're not your eyes actually not wandering. It's actually just being in the right place for you to see appropriately and to not see double. And so here's what I was mentioning about the penlight, and this is kind of you see how the pen lights on the outside and you can do this in your clinic when you see a face and you're and you're thinking, Hey, this I might go out, the side might go in Let me see what's going on And so you can see here if the if the lights on the outer portion it has to be centered on one. If it's centered on both Amazon straight, if it's centered and it's on the outer room of the people, that means this size in If it's centered on one and then the I it's on the inner part of the iris, then, yeah, that eyes going out. And so that's like in these patients these air extra traffic. But in the pseudo extra traffic patients actually normal. Finally, it is also hypertrophy in hypertrophy. That just means the hype up on the ice down, and that could be seen in fourth year policies, among other things. So for our patient, intermittent extra topia variable onset six months or six years of age, the eye goes out sometimes is probably very common thing you guys hear about a new clinic thes should be seen by us. Um, you know what we do often time depends on how well they how well did they fix it. And so if they if they like this kid, look, she's seeing straight here. And then she squinting along sunlight. But then sometimes the eyes out. If she sings straight the majority of the time and then she the eye wanders and she blinks and she brings it in. We classify that is, uh, classified that it's fair. Um, if she could do it without blinking, just you snap your finger to pull Zion. That's good. And we don't actually do, sir, I don't do surgery for that. And even for fair, I typically won't do surgery on. But for poor on poor, a progressive kind, I will consider doing surgery, and so here's kind of the way. Like and even before surgery, we consider different things, like over minus glasses. And it's basically what that that does is that pushes the kids I to focus even in the distance. So they have toe focus a lot to focus in the distance, and that makes them toe always kind of be on guard. And hate sometimes works really well for intermix utopia and getting them to where they have at least good control. Um, and finally, if I consider served as I mentioned. If, um, if they're constantly extra tropical or if they're like 90% of the time extra traffic. Because, like I said, I want to preserve their ability to see three D vision and and And yeah, Andi, in some cases, the way to go eso Here are some of the surgical methods that we use The most common is bilateral lateral rectus recession. Andi Then on Ben, you just you know, you just follow them afterwards and you still ah, lot of time. These kids have amblyopia and you have got to treat amblyopia while you're doing while you're after you do the surgery. Because these kids have a tendency, thio regress. And even if you do the service that can start wandering. And if you're not treating the underlying in Ethiopia. So this kid was, as I mentioned, Internet next topia good control, because the months that only happens in the fire. So I'll probably try over minus classes for them on, then see them in three months. And if it worsens in the future, you could consider surgery, but definitely not right now. All right, there's the last one patients a five year old male that I looked up for four months. But the eyes also read. So the mom was like I wasn't red originally, but now it's red and her son is now reporting pain. So on exam, you see a white dot and that actually is concerning. So, you know, typically you see a sky. I'm happy for you guys to treat the sky and, you know, do warm compresses do good lid hygiene. But if you ever see any white on the I have three kids in from Oakland who now have these types of white scars. They had a side, and it scratched the eye in the center, and now they have a scar along the like right on the visual access, and it affects their vision. And there really is no treatment that you have to a corneal transplant and eso It's like basically, I'm stuck because their visions 2040. I don't want to do a corneal transplant on them, and but, you know, it's If this had been caught earlier on this has been treated more aggressively at the beginning, it would have turned into this, and it's not just a sty. Oftentimes It's the kids who have more than one size and have crossed along their eyelashes, and they're not doing appropriately hygiene. If you ever see that the warm compress air good, a lot of time to see kids aren't agreeing. But if you see crusting along the lash space, it's really important for you guys. Thio recommended hygiene. There's a queue soft at CVS or Walgreens. Get that rub the lash bases aggressively and show them in the clinic how to do it. I show them in the clinic how to do it, and you'll be surprised that, like the outcomes are like dramatic. You'll see a kid whose eyes I was a complete mess up. You do that for, like, two weeks. They look like like nothing ever happened. But if you leave it, then this will happen and this will happen. It can happen along the visual access, and it can. It can cause some severe damage. Eso This is something if you the eye turns red on the sky and it's it. If it was, if it wasn't ready to begin with, just get them to us relatively soon, right? And here's some information about some of the West 18 and on who you can contact over there. Um, Aziz Well, and there's some more members of the East Bay team Dr Cox was including today. If we have, like, toasts patients, he sees them, and Dr Sue is Alexandra Moen, and she does a great job out there as well. And then pediatric glaucoma doctor Oates will accident Doctor Oates and then Doctor d'Alba. People still do a lot of data on neutral business, and and there's a neuro. There's two neuro pediatric neural models out there who do. A great job is well, and we send patients out there to them if it's very complicated and were concerned about different things that we don't treat on a regular basis.